Veterans Affairs, Veterans Health Administration, Department of Veterans Affairs
This position is located in the Revenue Section of Fiscal Service within the Dayton VA Medical Center.
The Medical Records Technician (Coder) reports to the coding supervisor & is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.
The MRT will perform either inpatient or outpatient coding duties, or a combination of inpatient and outpatient coding duties.
Basic Requirements: Citizenship.
Citizen of the United States.
(Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with chapter 3, section A, paragraph 3g, this part.) Experience.
One year of experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records.
An Associate's Degree from an accredited college or university recognized by the U.S.
Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records); OR, Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding.
The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S.
Department of Education accreditor, or comparable international accrediting authority at the time the program was completed; OR, Experience/Education Combination.
Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.
The following educational/training substitutions are appropriate for combining education and creditable experience: Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, and one year above high school, with a minimum of 6 semester hours of health information technology courses.
Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S.
Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures.
Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder).
Persons hired or reassigned to MRT (Coder) positions in the GS-0675series in VHA must have either (1), (2), or (3) below: (1) Apprentice/Associate Level Certification through AHIMA or AAPC.
(2) Mastery Level Certification through AHIMA or AAPC.
(3) Clinical Documentation Improvement Certification through AHIMA or ACDIS.
NOTE: Mastery level certification is required for all positions above the journey level; however, for clinical documentation improvement specialist assignments, a clinical documentation improvement certification may be substituted for a mastery level certification.
See VA Directive and Handbook 5019, Employee Occupational Health Service.
English Language Proficiency.
MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C.
Preferred Experience: Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Coding Specialist-Physician Based (CCS-P), or Certified Professional Coder (CPC) Grade Determinations: GS-8 Experience.
One year of creditable experience equivalent to the next lower grade level.
This is the journey level for this assignment.
Outpatient MRTs(Coder) at this level perform the full scope of outpatient coding including ambulatory surgical cases, diagnostic studies and procedures, outpatient encounters, and/or inpatient professional services.
Outpatient duties consist of the performance of a comprehensive review of documentation within the health record to accurately assign ICD CM codes for diagnoses, CPT/HCPCS codes for surgeries, procedures and evaluation and management services.
They independently review and abstract clinical data from the record for documentation of diagnoses and procedures to ensure it is adequate and appropriate to support the assigned codes.
They code all complicated and complex disease processes, patient injuries, and all procedures in a wide range of ambulatory settings and specialties.
They also directly consult with the clinical staff for clarification of conflicting, incomplete, or ambiguous clinical data in the health record.
MRTs (Coder) must abstract, assign, and sequence codes into encoder software to support medical necessity, resolve encoder edits, and ensure codes accurately reflect services rendered.
They also review provider health record documentation to ensure that it supports the diagnostic and procedural codes assigned and is consistent with required medical coding nomenclature.
They also query clinical staff with documentation requirements to support the coding process.
They enter and correct information that has been rejected, when necessary.
MRTs (Coder) ensure audit findings have been corrected and refiled.
They also use various computer applications to abstract records, assign codes, and record and transmit data.
MRTs (Coder) may be assigned to a single facility or region, such as a consolidated coding unit.
Demonstrated Knowledge, Skills, and Abilities.
In addition to the experience above, the candidate must demonstrate all of the following KSAs: Ability to analyze the health record to identify all pertinent diagnoses and procedures for coding and to evaluate the adequacy of the documentation.
This includes the ability to read and understand the content of the health record, the terminology, the significance of the findings, and the disease process/pathophysiology of the patient.
Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient professional fee services coding.
Skill in interpreting and adapting health information guidelines that are not completely applicable to the work or have gaps in specificity, and the ability to use judgment in completing assignments using incomplete or inadequate guidelines.
References: VA Handbook 5005/122, Part II, Appendix G57, Medical Records Technician (Coder), Qualification Standard, GS-0675 The full performance level for the MRT (Coder) assignment is GS-8.
The actual grade at which an applicant may be selected for this vacancy is a GS-8.
How to Apply
Medical Records Technician
Medical Records Administrator
Records and Information Management Specialist
Local Hire (Customer Representative - Non-Medical Vaccine Support Staff)